Search

Objective To determine the effect and safety of sequential treatment with the low-molecular-weight heparin dalteparin and the direct oral anticoagulants rivaroxaban in patients with cancer- associated venous thromboembolism (VTE). Study design Observational study. Place and duration of study Department of Oncology, the Second Affiliated Hospital of Soochow University, between January 2017 and September 2019. Methodology Patients with active cancer, diagnosed with VTE and who received sequential treatment with dalteparin and rivaroxaban, were retrospectively reviewed. Logistic regression analysis was used to identify risk factors associated with VTE recurrence. Results Ninety-nine patients with active cancer were enrolled in the study. The median delteparin treatment time was nine days (5-20 days), and 2.8 months (1-6 months) for rivaroxaban. Sixty (60.6%) patients had eliminated VTE, and 39 (39.4%) had persistent VTE, but with relieved symptoms. No major bleeding was observed. Eleven (11.1%) patients had minor bleeding, including melena (5.1%), hematuria (3.0%), vaginal bleeding (1.0%), gingival bleeding (1.0%), and subcutaneous hemorrhage (1.0%). During the 6 months follow-up period, one (1.0%) developed pulmonary embolism, and seven (7.1%) experienced recurrent VTE. Univariate logistic regression analysis showed that bleeding occurrence and anticoagulant treatment duration were the two significant factors affecting VTE recurrence (p Conclusion Maintenance of rivaroxaban after initial dalteparin treatment could effectively reduce the risk of VTE recurrence and was well tolerated by patients with cancer-associated VTE. However, in the clinical practice, the treatment duration is often insufficient, so it is essential to follow-up these patients to ensure sufficient treatment time. Key Words: Venous thromboembolism, Low-molecular-weight heparins, Directly oral anticoagulants, Cancer.

BACKGROUND The ONSTEP technique is a surgical repair method that uses an anterior approach for inguinal hernias. It is a new surgical technique that spans layers in which the medial side of the mesh is inserted into the peritoneal cavity, and the lateral side is positioned over the internal oblique muscle. Previous reports on this technique have mentioned the use of PolySoft Hernia Patch mesh; however, there have been no reports of surgical outcomes using OnFlex Mesh with absorbent rings. MATERIALS AND METHODS The authors evaluate the results of the ONSTEP technique using OnFlex Mesh. In 2017, this technique was introduced as an outpatient surgical procedure at our institution. In the past 3 years, it has been performed in 941 patients to repair 986 lesions. RESULTS Recurrences were observed in only 1 patient (0.10%), and complications included subcutaneous hemorrhage in 21 patients, hematoma in 10, seroma in 9, wound infection in 4, and mesh infection in 1. No serious events, such as postoperative ileus, chronic pain, or bladder injury, were observed. Because this technique does not require a procedure to detach the lateral preperitoneal space, the duration of surgery was 27±8 min, which was shorter than other transinguinal preperitoneal repair techniques. CONCLUSIONS The ONSTEP technique using OnFlex Mesh is a simple and safe repair method that can be performed as an outpatient surgical procedure. Although there is still a need to wait for long-term results, favorable short-term to medium-term results have been obtained.

The patient was an 88-year-old woman with a 10-year history of hypertension. She was suspected to have been hit by a car. At the time of the event, she was conscious and able to stand on her own and had no obvious injuries. She was sent home, but she lapsed into unconsciousness and was nonresponsive after 2 hours. She was sent to the hospital, and her heartbeat and breathing stopped. After half an hour of rescue attempts, her heartbeat did not recover, and she was declared dead. During the autopsy, a small subcutaneous hemorrhage was observed below the right knee joint. No obvious internal organ injuries or bone fractures were observed. The deceased also had mild atherosclerosis in the coronary arteries and an old cerebral infarction in the right cerebellum. The tissue histopathological tests showed distinct fat embolism in multiple organs, including the brain, lungs, kidneys, liver, and pancreas. A postmortem blood biochemistry test of the heart blood showed that the levels of low-density lipoprotein, cholesterol, triglycerides, and free fatty acids in the blood were increased, and the level of C-reactive protein was elevated. According to the autopsy results, the direct cause of death was multiorgan fat embolism. This case suggests that aging, hypertension, and hyperlipidemia may be risk factors for nontraumatic fat embolism under stressful conditions.

Context: Deep vein thrombosis (DVT) is a well-known complication of spinal cord injury (SCI). Low-molecular-weight heparin (LMWH) may be used in SCI patients who develop DVT, but can lead to subcutaneous bleeding. If subcutaneous bleeding occurs, then lymphedema, cellulitis, muscle or tendon tearing, or baker’s cyst rupture should be considered in the differential diagnosis. Findings: Herein, we present a 61-year-old female patient who was hospitalized for rehabilitation due to paraplegia, and used LMWH due to DVT development. The patient suddenly developed pain, swelling, and discoloration of the left lower extremity. Although subcutaneous hemorrhage was considered initially, ultrasound and MRI revealed a ruptured Baker’s cyst. In addition to supportive therapy, ultrasound-guided aspiration was performed. Conclusion/Clinical Relevance: In this report, we present a case of clinically severe Baker’s cyst rupture, which occurred in the lower extremity of a SCI patient using LMWH due to DVT in the same extremity. To our knowledge, no similar cases have been reported.

PURPOSE: We aimed to evaluate the clinical benefit of (125)I seed brachytherapy under DynaCT guidance for palliative local treatment of bone metastases. METHODS: From December 2014 to September 2017, 82 patients with painful bone metastases, who experienced treatment failure using standard strategies or rejected treatment were enrolled in this retrospective study. All patients underwent (125)I seed brachytherapy under DynaCT guidance. Technical success, visual analogue scale (VAS), numerical rating scale (NRS), verbal rating scale (VRS), Karnofsky performance status (KPS) and complications were analyzed. RESULTS: The success rate of (125)I seed implantation was 100%. The VAS and NRS scores for the most severe pain were 7.0 (5.0–9.0) and 8.0 (6.0–9.0) before brachytherapy. The pain scores assessed every 2 hours gradually decreased within 12 hours (p < 0.001). A comparison of KPS scores showed that patients had significantly better quality of life on weeks 1, 4, and 8 than on week 0 (p < 0.001). The associated complications were mild subcutaneous hemorrhage 25.6% (21/82), fever 7.3% (6/82), minor displacement of radioactive seeds 5.0% (4/82), pathologic fracture 2.4% (2/82), and local skin reaction 2.4% (2/82). After symptomatic treatment, all complications were relieved. Minor displacement of radioactive seeds did not cause damage to adjacent tissues. No serious life-threatening complications occurred in the study group. CONCLUSION: DynaCT-guided (125)I seed implantation is a safe and effective method for palliation of painful bone metastases from cancer after failure or rejection of conventional treatments.

A case involving an adult dismembered body with myositis ossificans (MO) is described. A woman in her 20s was found dead in her cohabitants' room. The body had dismembered into 15 pieces. Computed tomography showed ectopic mineralization in the bilateral upper arms and thighs. On autopsy, the skin and soft tissue were in the process of adipocere formation. Darkened areas that appeared to be subcutaneous hemorrhage were distributed on the face, left chest, and back. Bilateral upper arms and thighs showed organized granulations adherent to underlying bone. Microscopically, these organized lesions represented mature bone tissue in the periphery, cartilage tissue in the middle layer, and fibrotic tissue in the central part. These were typical findings of MO. Myositis ossificans and subcutaneous hemorrhage seemed to be evidence of antemortem repetitive physical abuse. In cases of dismemberment, the absence of organs and parts of the body provide limitations to determining cause of death. In forensic fields, adult autopsy cases involving MO are rare. This is an unusual case in which MO revealed antemortem physical abuse despite dismemberment of the body.

To investigate the efficiency of high ligation, great saphenous vein stripping and subfascial perforator vein surgery for treating great saphenous vein varicosis under the assistance of sterilized electric pneumatic tourniquet and Esmarchs bandage. In total, 274 patients confirmed with primary varicosis between January 2014 and November 2017 were included in this study. Patients were divided into 1.treatment group (n = 137), received high ligation, great saphenous vein stripping, and subfascial perforator vein surgery under the assistance of sterilized electric pneumatic tourniquet and Esmarchs bandage; and2.control group (n = 137), received high ligation, great saphenous vein stripping, and subfascial perforator vein surgery only. After surgery, the affected limbs in both groups were wrapped up using the elastic bandage for 2 weeks, followed by wearing elastic stocking for 6 months. Then we analyzed the intraoperative bleeding, surgery time, subcutaneous hemorrhage after surgery and postoperative pains. The surgical time in the treatment group was significantly lower than that of control group (58.62 ± 7.47 minutes vs 76.35 ± 9.24 minutes, P

To investigate the effect of different pressing time on the incidence of subcutaneous hemorrhage of low molecular weight heparin (LMWH) administration by meta-analysis. Cochrane Library, PubMed, MEDLINE, CINAHL, EMbase, Springer, EBSCO, China Biomedical Literature Database, CNKI, Wanfang Database, and VIP Database were searched. To screen the literature of randomized controlled trials with different pressing time in patients with subcutaneous LMWH injection from the establishment of the database to December 2020. The quality of the literature was evaluated and the data were extracted. Meta-analysis was performed by RevMan 5.3. A total of 17 randomized controlled trials were included. Meta-analysis showed that the bleeding rate of pressing for 5 min odds ratio (OR = 3.89, 95% confidence interval [CI]: 2.68-5.64, P

Rationale: Felty syndrome is a rare and life-threatening type of rheumatoid arthritis (RA). Patient concerns: A patient with RA had skin rash and subcutaneous hemorrhage, with a significant decrease in blood hemoglobin (Hb), white blood cell count (WBC), and blood platelet count (BPC). Diagnoses: The patient had a history of RA, splenomegaly, decreased Hb, WBC, BPC, and normal immunological indexes, combined with a series of bone marrow related tests and genetic tests. Interventions: She was given high-doses of glucocorticoids intravenously, followed by oral prednisone and cyclosporine maintenance therapy. Outcomes: Her symptoms were resolved within 2 weeks after the start of immunosuppression. After 2 weeks of discharge, the Hb, WBC, BPC basically returned to normal, and prednisone gradually decreased. Lessons: Felty syndrome is a rare complication of RA. Reductions in Hb, WBC, BPC, and subcutaneous hemorrhage should be considered strongly as the possibility of Felty syndrome. Multi-disciplinary diagnosis and related tests of bone marrow and genes are helpful for diagnosis and correct treatment.

The objectives of this study were to compare the results of radiofrequency ablation (RFA) and stripping for large-diameter varicose target veins for the period of 1 year, based on a composite end point; to analyze the pain severity on a digital rating scale for 7 days after RFA and stripping; and to detect the factors affecting the level of postoperative pain using the cluster analysis.This was a multicenter retrospective cohort study. Two groups, stripping ≥14 mm and RFA ≥14 mm, of 129 varicose vein disease patients underwent surgical treatment in three specialized clinics. We eliminated symptomatic pathologic reflux with RFA in 64 patients and with stripping in 65 patients. In the postoperative phase, we evaluated the pain level, subcutaneous hemorrhage, and paresthesia. A composite end point with four components was used to analyze the results. These were three clinical adverse effects of the intervention (pain, hemorrhage, and paresthesia) and the technical outcome 1 year after the surgical intervention.The frequency of favorable outcomes was 20 (30.8%) in the stripping ≥14 mm group and 61 (95.3%) in the RFA ≥14 mm group (P .0001). The odds ratio for a favorable outcome between the RFA and the stripping groups was 45.8 (95% confidence interval, 44.5-47.0). The pain clusters that were moderate were created by patients after stripping. These clusters show a link between the pain level on the one hand and an increased body mass index and large vein diameter on the other hand.For large-diameter veins, RFA is superior to stripping in terms of favorable outcomes according to the composite end point chosen. Significant pain after stripping was linked to a large vein diameter and excess weight or adiposis.

We herein report the cases of two elderly patients with acquired hemophilia A (AHA) for whom treatment was difficult.An 89-year-old woman (Case 1) was admitted to our department with subcutaneous hemorrhage and melena. Her activated partial thromboplastin time (APTT), factor VIII activity, and factor VIII inhibitor level were 127.7 seconds, 1.0%, and 48 BU/mL, respectively, which was suggestive of AHA. The administration of prednisolone (PSL 0.5 mg/kg) was initiated. After 3 weeks, PSL was combined with cyclophosphamide (CPA 50 mg). Two months after the start of treatment, her factor VIII inhibitor level decreased to 3.4 BU/mL. However, hemorrhagic signs were repeatedly observed during the discontinuation of recombinant activated factor VII (rFVIIa) preparation; bleeding control became insufficient, and pneumonia developed, thus leading to a fatal outcome.An 81-year-old woman (Case 2) was admitted to our department with subcutaneous hemorrhage, anemia (Hb: 9.2 g/dL), and a prolonged APTT (78.7 seconds). Her factor VIII activity was reduced to 0.9%, and her factor VIII inhibitor level was markedly increased to 1,364.9 BU/mL, suggesting AHA. Treatment with PSL (0.5 mg/kg) was initiated. After one month, it was combined with CPA (50 mg); however, her hemorrhagic signs were protracted, and her Hb level decreased to 8.0 g/dL. Subsequently, pneumonia occurred. However, weekly rituximab therapy (375 mg/m2) for 4 weeks decreased her factor VIII inhibitor level, leading to the disappearance of the inhibitor at 1 year and 5 months. During this period, there were no episodes requiring the administration of bypassing agents, such as rFVIIa.

In this issue of the journal the possibility that heme oxygenase activity is responsible for the delay in the appearance of the yellow color in bruises has been investigated [1]. Although bruises may have been a ‘‘very much neglected branch of injuries’’ [2] for many years, recent investigations, including the current paper [1] have revealed some unexpected and highly relevant findings. Bruises in the skin and subcutaneous tissues occur when there has been extravasation of blood following the application of blunt force. Generally the requirements for their formation are injury, compromise of the integrity of vessel walls, and blood pressure [3]. The most useful bruises in a forensic context are those that have a patterned appearance reflecting the nature of the impacting object. Questions that are commonly asked in court regarding bruises involve their age, the amount of force required for their production, and whether they occurred before or after death. Although it was once considered possible to provide answers to all of these queries, recent studies have shown that forensic assessments, particularly of the age of these injuries, may be less reliable than was previously considered. For example, it was once generally accepted that bruises could be dated from their macroscopic appearance and standard text books gave quite precise times for this, with bruises appearing red, purple, and swollen in the first 2 days, green from 4 to 7 days, yellow from 7 to 10 days, with resolution between 14 and 30 days. Of note, even then there was disagreement among the texts in the exact timeline for these color changes [4–7]. The paper by Langlois and Gresham in 1990 debunked this certainty, and demonstrated that the only reliable comment that could be made was that yellow bruises were likely to be older than 18 h [8]. It should be noted, however, that this study did rely on photographs of bruises, which may present additional complication in interpretation (see below). The reasons for the great variation in individual bruising responses to blunt trauma are varied and include differences in the nature of the impacting object and forces, age of the victim, variations in subcutaneous tissue thickness, variability in bleeding tendencies, the effects of underlying disease states, the influence of medications (both pharmaceutical and herbal) [9], and background skin pigmentation. Other issues concern considerable interobserver variability in the perception of yellow in bruises [10] and in the identification of specific colors [11], i.e. one observer’s brown may be another observer’s yellow, and the tendency for single bruises from one episode of trauma to develop different colors in different areas at the same time. All of this tells us that dating of bruises macroscopically is, at best, highly inaccurate. Photographing bruises introduces further variables as a bruise can be made to disappear if a picture is overexposed; in addition, an apparent ‘‘bruise’’ can be created if shadows occur from under-exposure. For this reason photographs should not be relied upon for the assessment of the age of bruises. Ideally bruises should be photographed in color at autopsy in suspicious cases, both before and after incision (the latter to confirm the presence of subcutaneous hemorrhage). Photography in black and white using infra-red or alternative light source illumination may provide additional information, and trace wound patterns may be detected by use of an alternative light source (although alternative light source [polilight ] illumination with digital image analysis does not assist in determining age). R. W. Byard (&) N. E. I. Langlois Discipline of Anatomy and Pathology, Level 3 Medical School North Building, The University of Adelaide, Frome Road, Adelaide, SA 5005, Australia e-mail: roger.byard@sa.gov.au

To protect children from abuse, it is important to identify victims at an early date, but diagnosis is often difficult. We used ultrasonography for objective examination of bruises arising from subcutaneous hemorrhages, and determined whether we could precisely measure the depth and thickness of a subcutaneous hemorrhage. We compared macroscopic findings, microscopic findings and ultrasonographic images of 10 bruises in forensic autopsy cases. In addition, we measured chronologic changes in subcutaneous hemorrhages using ultrasonography of 16 bruises in healthy volunteer children. Mild or moderate subcutaneous hemorrhages spreading along the fibrous partition in subcutaneous fatty tissue were observed by histological examination. There was a thickened fibrous partition or an isoechoic or hyperechoic area in the ultrasonographic images. A good correlation between the thickness of the subcutaneous hemorrhages by macroscopic examination and by ultrasonographic imaging was found in postmortem cases. We were also able to confirm objectively that the thickness of the subcutaneous hemorrhage of healthy children decreased with time. It is possible to measure the depth from the skin surface to the subcutaneous hemorrhage, and the thickness of the subcutaneous hemorrhage accurately using ultrasonography. Thus, the age of a bruise can be estimated more precisely using information on the subcutaneous hemorrhage from ultrasonography in addition to established evaluations by the naked eye and by spectrophotometry.

We describe a patient with subcutaneous hematoma associated with manual cervical massage during carotid artery stenting. A 73-year-old man with left cervical carotid artery stenosis presented with left amaurosis fugax. We performed carotid artery stenting using distal embolic protection with balloon occlusion. Dual antiplatelet therapy was maintained in the periprocedural period and an anticoagulant agent was administered during the procedure. Because the aspiration catheter became entrapped by the stent, it did not reach the distal side of the stenotic lesion, and manual compression of the cervical region was therefore performed. Immediately afterwards, a subcutaneous hemorrhage occurred in the cervical region. There was no postoperative dyspnea due to enlargement of the hematoma, which was absorbed spontaneously. Cervical subcutaneous hematoma can occur in the cervical region due to cervical massage in patients who are receiving adjuvant antiplatelet therapy and anticoagulation therapy.

Aim: Hemorrhage is an important complication of heparin-thromboprophylaxis after surgery. We attempted to clarify the incidence rate of prolonged activated partial thromboplastin time (APTT), representative of hemorrhagic tendency, in Japanese women who received thromboprophylaxis with unfractionated subcutaneous heparin administration after cesarean section (CS). We also determined factors which affected postoperative APTT. Methods: We studied 280 women who were administered thromboprophylaxis with unfractionated subcutaneous heparin 5000 IU two times per day after CS. Postoperative APTT under heparin was measured and the incidence of its prolongation was determined. Preoperative APTT, blood loss during surgery, postoperative hematocrit, postoperative serum total protein level, and postpartum body weight were measured, and their correlation with postoperative APTT was determined. Results: Preoperative and postoperative APTT values were 28.3 (26.7–30.3) and 33.8 (31.0–37.5) seconds for median (interquartile range), respectively. Overall, 7.1% of patients showed ≥45 s postoperative APTT. Two patients (0.7%) showed ≥60 s APTT, one of whom suffered subcutaneous hemorrhage around the abdominal incision with complete healing. There were no other hemorrhagic complications. Preoperative APTT positively, and postpartum body weight inversely, correlated with postoperative APTT. The amount of blood loss, postoperative hematocrit, and postoperative serum total protein level did not correlate with postoperative APTT. No discernible deep vein thrombosis or pulmonary embolism occurred. Conclusion: Although 7.1% of women under heparin-thromboprophylaxis showed a prolonged APTT that was 150% of the preoperative APTT, serious side effects were not observed. Subcutaneous administration of unfractionated heparin, if checking APTT prolongation 1 day after surgery, may be safe method of thromboprophylaxis after CS.

Aortic aneurysm is a rare cause of disseminated intravascular coagulopathy (DIC). We present the developmental course of DIC in a 70-year-old male patient who had a thoracoabdominal aortic aneurysm characterized by a progressive descending aortic aneurysm presenting as subcutaneous hemorrhage of acute onset. He was diagnosed as having aortic aneurysm–induced DIC. After adequate infusion of blood components, surgical repair of the descending aortic aneurysm was carried out successfully. The patient's bleeding tendency stopped dramatically in the early postoperative period as identified by clinical and laboratory findings. We concluded that the occurrence of DIC was due mainly to the progressive descending aortic aneurysm in the present patient and that surgical repair could be the definitive treatment of DIC in this setting.

Objective – To investigate the efficacy of low dose of botulinum toxin type A (BTX-A) for facial synkinesis and hyperlacrimation. Material and methods – Eleven patients suffering from facial synkinesis after Bell's palsy or facial nerve injury were treated with a low dose of BTX-A, 0.5–1.25 U per point into several points. One patient showing hyperlacrimation was also treated with BTX-A. The whole observational period was 43 months. Results – On average, 5.76 U of BTX-A, which was lower than that of previous reports, was injected per treatment. In seven cases, synkinesis disappeared completely after three or fewer sessions of BTX-A injection. The mean interval between treatments was 14.5 weeks. Hyperlacrimation was completely suppressed after a single subcutaneous injection of BTX-A. Only mild subcutaneous hemorrhage was observed as adverse reactions. Conclusion – Facial synkinesis can be treated with a lower dose of BTX-A without relevant adverse reactions.

In this study, we retrospectively analyzed 141 cases of hanging and 178 cases of ligature strangulation recorded in the Shanghai Municipal Public Security Bureau between January 2001 and December 2014 to explore the characteristics of hanging and ligature strangulation and to supply a scientific reference for forensic pathology. Several significant differences between hanging and ligature strangulation were found. Hanging cases were mostly suicide, with some accidental cases. Strangulation cases were mostly homicide, with a few cases of suicide or sexual asphyxia. Male hanging was more common than female hanging, with a ratio of 5:2. However, there were more female than male strangulation cases, with a ratio of 13:5. The ligature marks in hanging cases were almost all of a "U" type and above the hyoid bone. The ligature marks in strangulation cases were almost always a closed circle, but the position varied. The most common vital reactions were subcutaneous hemorrhage, exfoliation and blister, which are strong evidence of antemortem injury. Hemorrhagic spots were found on the temporalis, scalp, chest and back in strangulation cases, but were rare in hanging cases. Hemorrhagic manifestations were most common in the sternocleidomastoid muscle in hanging cases, and in the sternohyoid and sternothyroid muscles in strangulation cases. Fractures occurred in only ∼17% of victims. There are notable differences between hanging and ligature strangulation, which can help distinguish between these causes of death. These characteristics should be considered in forensic practice.

VEGF family members play important roles in angiogenesis and vascular permeability. VEGF-A-transgenic mice showed an increased vascularization with edema due to hyper-vascular permeability and subcutaneous hemorrhage as side effects. VEGF-A binds and activates two receptors, VEGFR-1 (Flt-1) and VEGFR-2 (KDR/Flk-1). To dissect the signals of these two receptors, we generated transgenic mice overexpressing either the VEGFR-2-specific ligand VEGF-E(NZ-7) or VEGFR-1-specific ligand PlGF-II under the control of the Keratin-14 promoter. VEGF-E-mice showed a significant increase in vascularization (about 10-fold compared to control mice) in subcutaneous tissues, whereas PlGF-mice showed only a 2-3-fold increase. Interestingly, VEGF-E-mice did not show any clear edematous lesions or hemorrhagic spots on the skin. Microscopically, VEGF-E-induced capillary networks have a well organized structure with the recruitment of pericytes. These results indicate that VEGF-E is a new angiogenic agent with less side effects for clinical usage.

This article presents the results of the evaluation of the effectiveness of physiotherapy during the postoperative period following rhinoplastic surgery based on the analysis of the dynamics of the clinical symptoms in 374 patients divided into two groups. The main group was comprised of 286 (86.5%) patients who had undergone the comprehensive postoperative rehabilitation with the use of the chosen physiotherapeutic procedures while the group of comparison consisted of 88 (23.5%) patients treated othrerwise. The method in question included the microcurrent lymphatic drainage, the magneto-laser treatment, and ultraphonophoresis. The data obtained give evidence of the significant differences between the two groups of the patients in terms of reduction of oedema of the nasal and facial soft tissues on days 10-12 and 30-35 after the treatment as well as of subcutaneous hemorrhage and pain in the external nose on days 10-12. These effects were more pronounced in the patients of the main group. The local subcutaneous compaction was documented in both groups (though it was more pronounced in the patients of the comparison group; p0.05) after the disappearance of the bulk of the swelling approximately on days 10-12. It is concluded that the results of the study confirm the effectiveness of the staged performance of various physiotherapeutic procedures during the postoperative period after rhinoplasty.Представлены результаты исследования эффективности физиотерапии после ринопластики на основе анализа динамики клинических симптомов у 374 пациентов. Основная группа - 286 (86,5%) пациентов, которым в полном объеме проводилась послеоперационная реабилитация по разработанной методике, и группа сравнения - 88 (23,5%) пациентов, которым она не выполнялась. Использовался микротоковый лимфодренаж, воздействие магнито-лазера и ультрафонофорез. При анализе полученных результатов отмечено наличие достоверных отличий между группами по параметрам уменьшения отека мягких тканей носа и лица на 10-12-е и 30-35-е сутки, а также подкожных кровоизлияний и болезненности наружного носа на 10-12-е сутки, что было более выражено в основной группе. Локальные подкожные уплотнения появлялись в обеих группах после исчезновения основной массы отека примерно на 10-12-е сутки и были более выражены в группе сравнения (р0,05). Полученные результаты подтвердили эффективность поэтапного выполнения различных физиотерапевтических воздействий в послеоперационном периоде после ринопластики.

Amyloidosis is a heterogeneous group of diseases in which misfolding of extracellular proteins is the pathogenic factor. Light chain amyloidosis (AL) is the most common form of amyloidosis, and the causative proteins in AL are the immunoglobulin light chains produced by clonal plasma cells. Hemorrhagic events, ranging from mild subcutaneous hemorrhage to life-threatening bleeding, account for a significant proportion of morbidities and mortality in AL patients. Deficiency of factor X from deposition into amyloid fibrils has been reported to be the most common acquired factor deficiency in AL. We herein report 2 patients with acquired factor X deficiency in AL. A 55-yr-old woman with AL had a prolonged prothrombin time (PT) and an activated partial thromboplastin time (aPTT) of 2.51 International Normalized Ratio (INR) and 75.1 sec, respectively, which were corrected on mixing with normal plasma. Factor X activity was markedly decreased at 5%. The other patient was a 67-yr-old man with AL with a PT of 1.63 INR and an aPTT of 50.3 sec, which were corrected on mixing with normal plasma. Factor X activity was decreased at 17%. Neither of the patients had apparent hemorrhagic manifestations. Identification of acquired factor deficiency and timely coagulation tests are needed in the diagnostic workup and management in AL.

Severe hemophilia patients are more likely to be complicated by intra-articular hemorrhage, subcutaneous hemorrhage, and intra-mascular hemorrhage. Spontaneous intra-abdominal hemorrhage is a rare fatal disease, which is an arterial bleeding of uncertain causes from vessel feeding arteries. In case the spontaneous intra-abdominal hemorrhage is complicated to severe hemophilia patients, the mortality rate increases considerably. We experienced a patient with severe hemophilia A, who made a full recovery from spontaneous intra-abdominal hemorrhagic shock by replacement therapy of coagulation factor VII, a noninvasive procedure.

We report a rare case in which life-threatening subcutaneous hemorrhage following minor blunt trauma developed in an elderly patient taking ticlopidine and aspirin. An 82-year-old woman taking ticlopidine and aspirin tripped on a road. She noted only mild pain at the left lower abdomen. However, the hematoma gradually enlarged, and she developed hemorrhagic shock. Emergently performed contrast-enhanced abdominal computed tomography showed a large hematoma (20 x 10 x 7 cm), including contrast extravasation, which was located beneath the skin of the left lower abdominal quadrant and within the external and internal oblique muscles. Emergency pelvic arteriography showed massive contrast extravasation from the left superficial iliac circumflex artery. Transcatheter arterial embolization (TAE) was successfully performed, using gelatin sponge pledgets and micro-size stainless steel coils. After TAE, hemodynamics stabilized. The patient was discharged uneventfully on day 12.

We report a case of lethal acute aortic dissection revealed by a large ecchymotic area at the root of the neck; the subject was an 86-year-old man who died suddenly in his hospital room. His medical history included ischemic heart disease with pacemaker implantation and an aortic surgical prosthesis. Forensic autopsy showed a major subcutaneous hemorrhage in the neck and large left pleural and pericardial adhesions secondary to thoracic surgery. The cause of death was an acute aortic dissection. Large adhesions led to an extensive mediastinal hemorrhage, spreading to the subcutaneous tissues of the neck. This case report highlights the difficulties in differentiating between traumatic and pseudo-bruising during a death scene investigation. The etiologies of pseudo-bruising are reviewed.

Objective To compare hemorrhagic events between clopidogrel and ticagrelor in the Platelet Inhibition and Patient Outcomes (PLATO) trial. Methods We examined the FDA Medical Review. Results Compared to clopidogrel, ticagrelor significantly increased spontaneous bleeds, major bleeds, major plus minor bleeds, and major plus minor plus minimal bleeds. Ticagrelor also increased both major and fatal/life-threatening bleeds versus clopidogrel when CABG was performed between 24 and 96h after stopping medication, which was also accompanied by a larger volume of chest tube drainage and transfusions. Moreover, ticagrelor increased CABG-related bleeding versus clopidogrel in those patients who did not wait until day 5 after stopping treatment to have CABG. Additionally, compared to clopidogrel, ticagrelor increased the risk of hematuria (RR=1.91; 95% CI: 0.95–3.83), intracranial hemorrhage or subdural or other hematoma (RR 1.87; 95% CI: 1.02–3.42), subcutaneous hemorrhage, ecchymosis, hematoma (RR=1.63; 95% CI: 0.84–3.17), epistaxis (RR=1.49; 95% CI: 0.67–3.32), retroperitoneal hematoma or hemorrhage (RR=1.49; 95% CI: 0.53–4.19), gastrointestinal/anal bleed (RR=1.23; 95% CI: 0.93–1.64) and bleed/hematoma (RR=1.21, 95% CI: 1.02–1.43). Conclusions Clopidogrel is safer than ticagrelor in regard to bleeding. Additionally, ticagrelor's purported faster antiplatelet ‘offset' is substantially longer than its pharmacokinetics indicate. Considering the fact that the mortality, stent thrombosis and myocardial infarction ‘benefit' of ticagrelor have recently been challenged, and that the increase in stroke on ticagrelor has recently been shown to be worse than originally published, the decision to use ticagrelor over clopidogrel in the face of a higher risk for bleeds is not advised.

We investigated the effect of prothrombin complex concentrate (PCC) on the international normalized ratio (INR) and blood coagulation system in two emergent patients treated with warfarin for secondary prevention of cardioembolic stroke due to nonvalvular atrial fibrillation. An 80-year-old woman developed massive subcutaneous hemorrhage and swelling on her right upper extremity with weak pulsation of the right radial artery and had an INR above 10. An 83-year-old man had pleural effusion with an INR value of 6.69 and pleural puncture was immediately required. We administered 500 IU of PCC to the two patients (17.2 IU/kg and 12.5 IU/kg) with 10 mg of vitamin K. The INR decreased to 1.12 and 1.85, respectively, with an increase of plasma levels of protein C and coagulant factors IIa, VIIa, IXa, and Xa 10 min after administration. The plasma levels of the thrombin-antithrombin III complex increased (from 4.0 to 12.0 micro g/l and from 0.5 to 28.9 micro g/l, respectively, normal value

Neurofibromatosis is rare genetic disorder that predisposes patients to tumor formation. Although the clinical manifestations are variable, vascular malformations are known to occur. We report a case of life-threatening massive subcutaneous hemorrhage after minor trauma in a patient with neurofibromatosis. Physicians need to be aware that bleeding from vascular malformations, even in the subcutaneous space, may be life threatening.

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder that has three major features: multiple neural tumors, cafe-au-lait spots, and pigmented iris hamartomas (Lisch nodules). The purpose of this case report is to advise physicians of the danger associated with the progression of fast-onset massive hemorrhage to hemodynamic instability, which mandates rapid treatment to prevent the development of a life-threatening condition. A 64-yr-old woman with NF-1 was admitted to the Emergency Department (ED) because of a rapidly growing, 10 x 5 x 3 cm-sized mass on the left back area. She had previously undergone surgery for a large subcutaneous hematoma, which had developed on her right back area 30 yr before. She became hemodynamically unstable with hypotension during the next 3 hr after admission to ED. Resuscitation and blood transfusion were done, and the hematoma was surgically removed. The mass presented as a subcutaneous, massive hematoma with pathologic findings of neurofibroma. We report a case of NF-1 that presented as recurrent, massive, subcutaneous hemorrhage on the back region combined with hypovolemic shock.

We present a 16-year-old boy with mild hemophilia A who developed superficial fibromatosis mimicking subcutaneous hematoma of the right upper dorsal region of the foot. This condition is very rare. Hematoma originally developed after the patient sprained the right ankle. Although cast immobilization and replacement therapy with factor VIII (FVIII) concentrates reduced the symptoms, the swelling and pain reappeared in the same region 4 weeks after the cast was removed. A clinical diagnosis of intramuscular hemorrhage was made. Despite readministration of regular FVIII concentrates and cast immobilization, the patient experienced a relapse after removal of the second cast. Magnetic resonance imaging demonstrated a tumor in the extensor digitorum brevis muscle of the right foot with high intensity on T2-weighted images. Marginal excision resulted in symptom resolution. A histopathologic examination of the tissue showed proliferation of fibroblastic cells with abundant collagen bundles. When a mass is found under the skin in hemophilia A patients, an etiology other than bleeding can be overlooked because subcutaneous hemorrhage in limited areas often results in a mass; however, the possibility of rare soft tissue tumors in hemophilia patients should be kept in mind.

In this report, we describe a fatal case of pontine hemorrhage related with methamphetamine abuse. A 54-year-old male was found dead in a prone position in his parents’ house, and a medico-legal autopsy was carried out to determine the cause of his death. Externally, although an injection mark-like injury with subcutaneous hemorrhage was observed in the left cubital fossa, the autopsy revealed no severe trauma leading to death. Internally, every organ was moderately congested. The brain weighed 1330 g. Macroscopically, there was no vascular abnormality such as aneurysm or malformation. In the sections of the brain stem, a massive hematoma occupied the central area of the pons. Drug screening test using Triage™ was weakly positive for amphetamines. Moreover, in the blood and urine samples, methamphetamine was quantitatively detected at concentrations of 0.4 and 0.6 mg/l, respectively, by gas chromatography–mass spectrometry. Other drugs and poison were not detected in the blood and urine samples collected at autopsy. Histopathologically, necrotizing angiitis characterized by fibrinoid necrosis of the intima and media was observed with cell infiltration. Thus, the pontine hemorrhage seemingly resulted from methamphetamine-induced angiitis, with an acute elevation of blood pressure after methamphetamine abuse.

To determine the time-course of human subcutaneous hemorrhage, heme oxygenase (HO)-1 expression and macrophage infiltration were observed using an immunohistochemical technique and semiquantitative analysis. The number of immunoreactive cells and the number of all infiltrating cells of each microscopic field were counted, and the ratio of the former to the latter was calculated as the positive cells ratio. An increase in the HO-1-positive cells ratio was observed starting at 3 h after injury, and the maximum ratio was observed 3 days after injury. The pattern of the increase in the macrophage ratio was similar to that of the HO-1-positive cells ratio in the early period after injury. Observation of serial sections revealed that the expression of HO-1 in the cells corresponded to the localization of macrophage. The present results suggest that the determination of HO-1 expression, as derived from macrophages, might be useful for the estimation of the time-course of subcutaneous hemorrhage.

An unusual case of traumatic basal subarachnoid hemorrhage (SAH) due to a mechanical tear of the basilar artery is reported. A 70-year-old man who had been suffering from cerebrovascular dementia was found dead in a ditch. Externally, subcutaneous hemorrhage with abrasions was observed on the left side of the forehead, face, and lower jaw, together with small contusions in the left superciliary arch. Internally, a 3-mm-long transversal tear of the basilar artery was observed, and dislocations of both C6-C7 and T1-T2 as well as a small fracture of the processus spinosus of C5 were found. No pathological vascular lesions such as aneurysms and vasculitis, other than arteriosclerosis, were observed in the vertebral-basilar system. Ethanol was not detected in the intracardiac blood or in the urine. These findings indicate that when the man fell into the ditch, severe hyperextension occurred as a result of minor blunt forces to the face, and that the traumatic tear of the basilar artery was mechanically caused by overstretching due to hyperextension of the head. It is also suggested that due to his advanced age the muscle tone of the neck might have declined, impairing its defense action, and that head hyperextension might, therefore, occur rather more readily under such conditions.

A 49-year-old man collided against an infielder when he slid into second base during a recreational baseball game. He was unable to continue in the game due to diffuse pain and swelling of his hindfoot. A rupture of the Achilles tendon was diagnosed incidentally on palpation and observation of a positive Thompson's squeeze test. Subcutaneous hemorrhage at the lateral aspect of the heel and a small bone fragment under the lateral malleolus on an anteroposterior plain radiograph indicated a fracture of the calcaneal wall. At surgery, a complete rupture of the Achilles tendon and an avulsion of the calcaneofibular ligament from the calcaneal wall were seen. Both injuries were surgically repaired, and the patient subsequently did well. The mechanism of injury was thought to be impact hyperdorsiflexion of the ankle with rupture of the Achilles tendon accompanied by an inversion injury. Using a literature search, it was found that this combination of injuries has not been previously reported.

Hirschsprung's disease has been considered to cause intestinal perforation in rare cases. Even if a perforation occurs, the majority of cases are associated with the long-segment or total colonic type. Our case developed the perforation in the neonatal period in spite of being of the recto-sigmoidal type, and it affected the cecum. We do not have a good explanation for this condition. However, the pathological examination of the specimens of the perforated cecum revealed some necrosis (ulceration, subcutaneous hemorrhage, congestion and severe edema) which was considered to be caused by ischemia, secondary to a localized vascular accident in the wall of the distended intestine.

A 30-month-old girl was evaluated with Ga-67 imaging to identify foci of abnormal inflammation. Biopsy of a cutaneous lesion demonstrated manifestations of periarteritis nodosa, which included polymorphic exanthemata-purpuric, urticarial, and multiform in character. There was also severe subcutaneous hemorrhage resulting from necrotizing arteritis. Ga-67 imaging shows the only abnormality located to the posterior neck muscles at sites of cutaneous involvement. Other areas were normal

SummaryChicks reared for 4 weeks on a modified non-fat milk diet deficient in copper developed mild anemia, leg weakness, bone deformities and a high incidence of subcutaneous hemorrhage. Mortality amounted to 23% and most deaths resulted from internal hemorrhage associated with rupture of major vessels. Histologic studies suggest a derangement of connective tissue metabolism with the major defect in elastic tissue.